A physiotherapy note is not just a legal obligation — it is proof of the quality of your work. In this article you will find a complete template compliant with standard requirements, filled-in examples, and the documentation audit checklist used by inspectors.
Legal requirements
Physiotherapy medical documentation must comply with the following types of regulations:
- Patient rights legislation governing access to and retention of medical records.
- Health ministry regulations on the types, scope and formats of medical documentation.
- Professional practice acts specific to physiotherapy.
- Data protection regulations (GDPR / local equivalents) for personal and sensitive data.
Mandatory elements of the note
- Patient identification data (name, surname, date of birth, ID/insurance number).
- Date and time of the session.
- Physiotherapist data (name, surname, professional licence number).
- Patient interview (complaints, history, risk factors).
- Physical examination (ROM, strength, special tests, palpation).
- Physiotherapy diagnosis / clinical hypothesis.
- Treatment plan and therapy goals.
- Description of procedures performed.
- Recommendations for the patient.
- Physiotherapist's signature (electronic or handwritten).
Download the template
Physical Therapy SOAP Note Template
Editable .docx file · Cora AI
Examples: initial visit and follow-up
Example — initial visit (lumbar pain)
S: Female patient (52 y/o), nurse, presents with a dull ache in the lumbar spine for 6 weeks, worsening with prolonged standing, radiating to the right gluteal region. VAS 5/10. No loss of sphincter control. Previous episode 2 years ago.
O: Posture: increased lumbar lordosis. Trunk flexion 60° with pain. SLR test (+) right at 60°. Slump test (+). Dorsiflexion strength 5/5. Sensation intact.
A: Suspected right-sided L5 nerve root irritation, likely discogenic in origin. Further screening for red flags indicated.
P: Manual therapy lumbar spine, stabilisation exercises (TrA, multifidus), ergonomic education. 2× / week for 4 weeks. Goal: reduce VAS to 2/10 within 4 weeks.
Example — follow-up visit
S: Patient reports pain reduction to 2/10. No radiation for 5 days. Tolerates 8 h of standing work. O: SLR 80° pain-free. CKC stabilisation adequate. A: Progress as planned. P: Progress to resisted exercises, reduce frequency to 1× / week, reassessment in 2 weeks.
SOAP vs narrative format
Both formats are widely accepted. SOAP is cleaner in audits and inter-specialist communication. A narrative format may be preferred for elderly patients or single consultative visits. We recommend SOAP as it is safer in the event of an external inspection or audit.
Documentation audit checklist
- ✅ Every note includes date, time and session duration.
- ✅ Pain scale recorded (VAS/NPRS).
- ✅ Therapy goals are SMART (specific, measurable, time-bound).
- ✅ Every visit ends with a "Plan" section.
- ✅ Patient consent documented before the first visit.
- ✅ Signature (electronic or handwritten) on every entry.
- ✅ No modification of the note after signing (additions only, with annotation).
„The most frequent audit finding: missing documented therapy goals and missing pain assessment scale. These two fields must appear in every note."
Most common formal errors
- Note entered 24+ hours after the session without a documented reason for the delay.
- Pain assessment scale omitted.
- Goals described as "improvement in patient condition" — without measurable parameters.
- Personal abbreviations that are incomprehensible to an auditor.
- Missing physiotherapist identification data (licence number).
Automation with Cora AI
All of the fields above are filled in automatically by Cora AI based on the conversation with the patient. The note is ready within 20 seconds of the visit and comes in the form of a complete SOAP note compliant with formal requirements. All you need to do is review, accept and sign.